It can work: Open employment for people with experience of mental illness

Abstract

BACKGROUND: Previous research has tended to focus on the barriers to employment for people with mental illness and the extra support they may need. This research contributes to the knowledge base pertaining to this population by looking at successful employment relationships in New Zealand.

OBJECTIVE: To describe factors enabling and/or sustaining the open employment of people with experience of mental illness.

METHOD: Fifteen pairs of employers and employees were interviewed individually but consecutively (using a semi-structured interview schedule) about their perceptions of the critical factors that enabled and sustained the employee’s employment. Employee participants were recruited by advertisement, with employers approached through their employees. Transcripts were analysed using a thematic analysis.

RESULTS: Themes raised in the interviews included the meaning of work, disclosure of mental illness, the benefits of working, special arrangements or accommodations, the work environment and key things employers and employees do to sustain successful employment.

CONCLUSION: Four critical success factors were identified relating to disclosure, the employment relationship, freedom from discrimination and workplace flexibility.

Keywords

Mental health disclosure psychiatric disability positive stories

1 Introduction

The statistics relating to mental illness and employment vary from country to country, but some generalisations can be made. People with experience of mental illness have very low employment rates and participation in the labour force [1 –14] and correspondingly higher unemployment rates than the general population [3 , 15–19]. For those diagnosed with schizophrenia, for example, employment rates are estimated to be as low as 10–20% [20, 21]. Further, under-employment is a big problem for those people who are employed [8 , 22]. In terms of the bigger picture, mental illness generally is a substantial contributor to absence from work [8 , 23–25]. As a consequence of employment difficulties, a high percentage of people with experience of mental illness receive government income support [18, 26].

About five percent of the New Zealand population (that is about 242,000 people) are living with long term limitations to their daily activities as a result of psychological and/or psychiatric impairments [27]. In New Zealand, of people with disabilities, those with psychological/psychiatric disabilities have the highest needs for workplace modification or support, mainly in the form of modifiedhours [28].

Nevertheless, there are many positive aspects of employment of people with mental illness. Work brings people a greater stability and structure to their lives [29], along with a sense of belonging and a sense of purpose [5, 29]. Work appears to promote: recovery of people with experience of mental illness [22 , 30–32]; social inclusion [10, 31]; and financial independence [7 , 30–34].

Employing people with experience of mental illness has positive benefits for workplace culture as well as for the individual. A workplace that reduces stigma and allows employees to seek help for mental health problems benefits that organisation [35]. Employers report benefits to their businesses from employing people with experience of mental illness and people with a disability in general. Benefits include improving workplace culture and the business’s reputation, a ‘feel good’ effect on employees and customers, and greater employee loyalty and commitment [36]. Other benefits to employers from employing people with a disability include reduced health and safety incidents and less absenteeism [37] in contrast to the earlier identified statistics on absenteeism more generally.

1.1 The New Zealand legal situation

Like other countries, New Zealand has legislation targeted at discrimination associated with disability (including psychiatric disability) in employment. New Zealand’s employment law is governed primarily by the Employment Relations Act 2000 and requires that both employees and employers act in good faith in all aspects of the employment environment and of the employment relationship. It is unlawful for an individual to be treated differently in employment (including through job advertisements, job interviews, job offers, working conditions and pay, being forced to retire or leave, or being fired) because of their experience of mental illness. Employers are obliged to provide reasonable accommodations, that is special services or facilities that are required to enable the employee to perform the role (unless it would be unreasonable to expect an employer to do so) and measures to reduce any risks to a normal level (unless it would be unreasonably disruptive).

1.2 Freedom from discrimination

Despite legislation, stigma and discrimination are seen as a major barrier to employment for people with experience of mental illness [16 , 39]. For some people this discrimination is more of a burden than their experience of mental illness [25]. In particular are the attitudes of employers – many of whom would not hire someone if they knew that person had experience of mental illness [4], and are unwilling to make reasonable accommodations in the workplace [38]. The beliefs that employers are acting on when they discriminate seem to be based on notions that a person with experience of mental illness: is incompetent; is socially inadequate; has extensive needs; is different to others; and will cause a loss of productivity [40]. Other attributes assigned to people with experience of mental illness are that they are unskilled, unproductive, unreliable, violent, and unable to handle pressure [40], perceived as dangerous, strange or at risk of relapse [41].

Workers with experience of mental illness may be discouraged from taking on certain projects, avoided by colleagues, passed over for promotion [42], excluded or alienated at work [25]. People may not complain because they do not want to be labelled as having a mental illness [43]. They may feel socially marginalised [32]. Those looking for work may fear discrimination, and self-stigma can stop people from seeking employment [13]. Reacting to this threat by trying to over-protect people with experience of mental illness may lead to exclusion from employment which is also a form of stigma [34]. Despite this, Corrigan [44] reports that there is no evidence that stigma and discrimination negatively affect the work goals of people with experience of mental illness.

Research has provided few solutions specific to the dilemma of stigma and discrimination associated with mental illness and employment, except to encourage people with experience of mental illness to work [6].

1.3 Disclosure

Disclosure of mental illness to employers, potential employers or work colleagues is a “personal, multi-layered and potentially difficult decision” [45 p2]. It involves careful planning, with the main risk to the person with experience of mental illness being a potentially discriminatory reaction [46]. The fear of discrimination, along with legal, practical and moral pressures contribute to an ongoing tension between workplace disclosure and non-disclosure of mental illness [47]. However, the benefit of disclosure is that appropriate accommodations can then be arranged in the workplace if necessary [48, 49]. As Niekirk [34, p463] reports, disclosure has a “remarkably positive impact on resolving experiences of otherness”.

Employers prefer potential employees to disclose their experience of mental illness prior to recruitment [23], though not all employers feel comfortable discussing mental health issues with job applicants [23]. On the other hand, many people with experience of mental illness chose not to disclose until after a job offer, fearing discrimination would preclude them from getting to this stage [45].

1.4 The workplace environment

Kirsh et al. [40] define accommodations as “changes that are made in a particular workplace environment or in the way things are usually done that make it possible for a person with a disability to do the job” [40 p396]. Provision of accommodations is associated with job satisfaction, the ability to cope with illness and maintain employment, and increased workplace productivity [14]. According to Shankar [32], people with experience of mental illness may need support in assessing the kinds of accommodations they need, and help in negotiating these with their employer. Reasons for accommodations may need to be explained to a person’s colleagues, to avoid resentment [6, 25].

Employers cannot provide accommodations if they do not know or could not be expected to know about a person’s disability [45], which means in order to arrange for workplace accommodations, a person must disclose their mental illness to their employer, risking discrimination.

The literature does provide some practical advice to employers about what to do and what not to do when employing someone believed to have experience of mental illness and guides have been produced to help employers do this, (for example [50]. An English publication [51] provides information for managers on how to support people with experience of mental illness within the context of supporting the wellbeing of all employees in the workplace. Employers can also create positive work environments to reduce the risk of depression and stress in the workplace, promoting mental wellbeing foreveryone [52].

There is extensive literature on the individualised placement and support (IPS) supported employment framework and its eight principles which have been successful in helping people with experience of mental illness into work [18 , 52–55] There is also a growing body of research that suggests that the best way forward for people with experience of mental illness to gain their desired employment outcomes is to take charge of their own goals or at least work in collaboration with health and employment services. Michon et al. [56] argue for self-management. This requires a range of skills: timing; self-reflection; communications and insight into one’s own strengths and problems [56]. Vital for the success of self-management is acceptance and support and a trusting relationship between colleagues or supervisor [56]. Interventions that allow for people to develop proactive coping strategies may also help reduce work interruptions [57], while Rinaldi and Killackey [31] argue that the most helpful interventions include: support from friends and family; receiving an accurate diagnosis; achieving the right levels of medication; support from employers; and people believing in their ability.

1.5 What makes for successful employment?

Employment success can be measured by gaining or maintaining employment. Research suggests an important predictor of employment success for people with experience of mental illness is previous employment [20 , 59]. Tsang [41] argues that while skills and qualifications are important, “social competence is the most significant predictor of vocational success among people with psychotic disorder” [41 p730]. For Waynor’s participants [60], a positive attitude to work and their mental illness seem to be the key to success.

Other factors that are seen to lead to employment success include: interpersonal factors such as family or professional support [15, 61]; employee self-care and self-awareness [46]; good cognitive function [61]; age – those who are younger are more likely to quit [61]; education [54]; positive workplace relationships [48]; availability of accommodations [48]; gender – males more likely to succeed [16]; and insight [17, 21].

Disputed factors are diagnosis and the severity of mental illness symptoms, with some researchers indicating that those with affective disorders are more likely to succeed in employment than those diagnosed with schizophrenia [16, 54] and other researchers stating diagnosis and symptom severity make no difference [20 , 44].

When one moves beyond measuring success in terms of job gain or tenure and into job satisfaction, job fit is seen as a more important predictor of success [7, 40]. It then becomes clearer that people withexperience of mental illness require the same things from a job as most employees. People with experience of mental illness “value a friendly, respectful, communicative work environment with a culture of flexibility and inclusion” [14 p34]. Villotti et al. [14] go on to state that job satisfaction is more related to the workplace environment (e.g accommodations, support from coworkers, occupational self-efficacy) than to external variables (e.g family support).

1.6 What we know

The literature on people with experience of mental illness and employment has tended to focus on the experience of two groups. The first is those with ‘severe’ mental illness, of whom only 10% are in paid employment [26]. Research for this group has focused on their ability to gain or maintain employment with the help of vocational services such as IPS services (of which there is a considerable body of research (e.g. Heffernan and Pilkington [18]) and their quest to return to work. The other group on whom researchers tend to focus are people with symptoms of common mental illnesses, who may experience temporary employment disruption [20 , 53–55]. These groups have different needs, although both are affected by stigma and discrimination [26] that impacts on their social inclusion.

Little research has focused on people who experience ‘significant’ mental illness but maintain their high level employment with little or no input from vocational services (one exception being Ellison et al. [62]). Our study contributes to the knowledge base pertaining to this group, from the perspectives of both the employee and the employer. Our research question was: what are the critical factors that enable and/or sustain open (not supported) employment of mental health service users?

2 Method

2.1 Sample

The study was undertaken throughout New Zealand. A collective case study method [63] was utilised for this research – each ‘case’ comprised of a pair – an employee and their employer. A mix of maximum variation and criterion based sampling strategies [64, 65] were used to identify potential employee participants with established mental illness. Participation was sought from people in a range of employment types – full and part time, permanent and contracted – with varying levels of organisational responsibility and in various settings – small and large private, government and non-government organisations in rural and urban environments. All employees in the study had to meet the criteria of being a mental health service user in open (not supported) employment. As well, employees were included in the study only if their employer also agreed to be interviewed. Employers were only interviewed for the research if they were approached through their employee, their employee met the criteria, and the employee agreed to be interviewed.

Fifteen employees were interviewed – eight female and seven males. Of the employers, 10 were female, 4 were male. Five of the employees were aged 23–34, eight from 45–54 and one from 55–65. In terms of ethnicity, 13 described themselves as New Zealand European, one as Samoan and one as Australian. The majority (n = 9) had experienced mental illness for over 20 years, with others reporting ranges of between three to five years (n = 2), 11 to 15 years (n = 2) and 16 to 20 years (n = 2). Participants had been employed in their current role between three months and 10 years. The number of hours worked per week ranged from eight to 43, with the majority (n = 10) working full time. Twelve had a permanent employment agreement, two a fixed term contract and one was self-employed. Eight were employed in the private sector, four, the public, or government sector, and three in the non-government or voluntary sector.

2.2 Procedure

Ethics approval was gained for the study from the University of Otago Human Ethics Committee (14/022). Informed consent was gained from participants. The research was overseen by an advisory group. Members of this group included people in positions and with the experience, expertise and perspectives to provide specialist legal, mental health, human rights, and cultural advice, and with social science and employment perspectives. Employees were recruited primarily by way of community newspapers and mental health service user and general disability information channels and networks. This specifically included forums and organisations whose purpose it is to provide information, news, resources, and support to people with experience of mental illness. Purposeful recruitment was also employed in the form of personal invitations to participate being extended to people whom the investigators and members of the study’s advisory group knew fitted the inclusion criteria and thought might potentially be interested.

Employees who expressed interest in participating were sent an information sheet. If they met the criteria of being a mental health service user in open employment and wished to pursue participation, they were asked to provide informed consent for the researchers to approach and invite the participation of their employer. Where such informed consent was given, the employer was then sent a personal invitation to participate and an information sheet. If the employer also agreed to participate, the employee and employer became participants in the research and were considered to be a ‘case’.

Semi-structured interviews, with two schedules depending on whether it was an employee or an employer being interviewed, were undertaken. Interviews were usually face to face although for five cases they were undertaken by phone. Participating employees and employers were interviewed separately, but consecutively at a place, usually the workplace, and a time of their convenience. The interviews lasted between 15 and 50 minutes.

2.3 Data

The interview guides were developed on the basis of current literature, the experiences of the researchers and in conjunction with the advisory group.

There were 14 questions in the employees’ interview schedule, and 16 in the employers. Questions for employees ranged from general information regarding the workplace, the employment process, specific questions about issues around mental illness and employment, disclosure, becoming unwell, comparing this job to others and the key factors that made this job positive and successful.

For employers, the questions were similar (except focused on their employee) with the addition of two others – the benefits of employing their employee, and any advice they would give to others thinking about employing someone with experience of mental illness.

2.4 Analysis

Each interview was digitally recorded then transcribed. The transcripts were sent to the participants for checking. Each pair of interviewed employees and employers was treated as one ‘case’, with 15 cases in total. Three groups were identified – the employee/employer pairs; the employees; and the employers. A thematic content analysis [66, 67] was undertaken within each group and between the groups utilising NVivo software. This was done by identifying categories in the data, connecting and finding relationships in the text within and between cases [68] and developing themes. We looked for both commonalities and differences. One author focused on developing and summarising the themes within the pairs, the other the employees and the employers. The themes were discussed and examined by both authors as part of a verification process. The authors worked together on the detailed results and findings.

3 Findings

The findings focused on nine themes and we examined both employee and employer views.

3.1 What work means

Employers were not asked about this. However, for employees, work provided a sense of satisfaction, responsibility and accomplishment that was motivating and fulfilling, as well as providing money, stability, security and support. Depending on the job, it enabled people to make a difference in others’ lives. Many felt it was a reason to get out of bed every day, and it also helped individuals grow as people.

3.2 Disclosure

Some employees were upfront with their employers from the start of their employment relationship, either disclosing at the application stage or in an interview. Two employees had previous employers who informed their future employer about their experience of mental illness. One person was asked about her situation in her job interview for an organisation that gave priority to employing people with experience of mental illness. Other employees disclosed after they had been employed, usually out of necessity – they had either become unwell and/or they needed to take time off because of their mental illness.

Several reasons were given for disclosing at the beginning of the employment relationship. It was the honest thing to do; the employer could appreciate where the person was at; employees with previous bad experiences could feel positive when they were not discriminated against; and feeling that disclosure meant their chances of being discriminated against in the future were lower. One person believed by disclosing in her curriculum vitae (CV), her experience of mental illness must have been accepted for her to get to the interview stage. However, one employer said that disclosing in a CV was inappropriate.

For those employees who did not disclose upfront, but did so when they became unwell, there was no sense that the employee did this deliberately to mislead. There was however, considerable stress associated with the decision as to whether to disclose or not at this stage.

Most employees had disclosed their experience of mental illness to at least one other colleague apart from their immediate manager. The effect had generally been positive, with employees reporting that they did not have to pretend, could fit in as ‘normal’, did not need to worry about how they were perceived, and could explain when things weren’t helpful in the workplace. One effect of disclosure reported by several employees was that others in the workplace had disclosed their own experiences of mental illness. One employee noted that disclosing her mental illness to her colleagues reflected her confidence rather than a need for validation.

No employers reported seeming surprised when their employee disclosed their experience of mental illness to them. One employer said she was glad she did not know initially about her employee’s mental illness:

It wouldn’t have changed my view of [the employee] I don’t think. You never know until you’re in the situation but I’m pleased I didn’t know. It didn’t give me the opportunity to say; oh no I’ll put her aside as a candidate.

Some employers were in organisations that asked pre-employment questions that included questions about health issues and disability in general. According to the employers, the questions were used as a way of identifying support needs. The questions could be used as a conversation starter in an interview, and a way of finding out if a person is fit for the role. Where the questions were specifically about mental illness, one employer felt that their organisation used these questions as a way to screen people. Another employer however, used these questions in order to meet a target of employing a specific number of people with experience of mental illness. Other employers never asked about health issues and disability because they saw no need.

3.3 The effects of mental illness on employment

Some employers observed no obvious effects of mental illness on the way their employees performed their jobs, although some of their employees reported negative effects. It seemed that the effects the employee noticed (for example not being as productive) were not outwardly observable.

When employers and employees agreed that there were negative effects, these were either in the past, time limited or seen as an acceptable part of having that person as an employee. Both parties had come to some form of arrangement in order to work around them or turn them into strengths for the job.

Some employers suggested their employee’s mental illness had a positive effect on the way they performed their job.

3.4 The benefits of employing the employees

Employers were asked if they or their colleagues, or their organisation experienced any benefits from employing their employee. The employees were described in glowing terms and the benefits went beyond those that good employees bring to organisations generally. They often talked in terms of qualities their employee brought to their organisation rather than benefits. These qualities included insight, respect (commended for their views as service users with lived experience), knowledge and honesty around their mental illness, creativity, confidence, professionalism, trustworthiness, supportiveness, resilience and credibility. These qualities were perceived as beneficial, by employers both inside and outside the mental health sector.

3.5 Special arrangements

We asked the participants about special arrangements made in the workplace for the employee with experience of mental illness. We meant, and this was interpreted as we meant it to be, reasonable accommodations (changes that are made to the environment or in the way things are usually done to meet an employee’s needs in relation to a disability). None of the employers mentioned their legal obligations to provide these reasonable accommodations, rather where they were provided the employer felt they were the right things to do.

Most of the special arrangements made in the workplace for employees due to their experience of mental illness were around increased flexibility of working hours, location, and sick leave arrangements. There were accounts of employees having arrangements with their employers to: work at home; take time to attend appointments; or take sick leave (paid or unpaid) where necessary.

I think there’s been one or two occasions where she has identified she needs more time off ‘cause she’s not feeling too well or she’s exhibiting early warning signs, but no different to anyone else who’s having sick leave

Where the arrangements were in place the employees did not always make use of them.

Many employers considered that the arrangements they made for their employee who had experience of mental illness were no different to those of other employees.

3.6 The work environment

Employees felt valued and cared for, and frequently cited the working environment as being one of the main reasons they enjoyed their work. The work environment was seen as important for all the employees we interviewed. The employers we talked to said they had deliberately decided to foster working environments that were friendly, respectful, fun and communicative. In comparison, previous workplaces were described as too stressful, people felt micro-managed and found it difficult to fit in to the workplace culture, with consequent negative impacts on wellbeing. In contrast, current employers were described as more positive, employees felt cared about and respected. Several people said the time spent in their current job was the longest they had ever had due to their enhanced working environment.

3.7 Key things employers do for successful employment

Both employees and employers identified things that employers did to make their employment positive and successful. These included:

maintaining an open door policy, with clear communication in both directions

creating a positive open work environment

encouraging and supporting employees

helping to manage people’s workloads

good ‘employer attributes’ (caring, empathetic, treating people fairly, high integrity)

being flexible.

3.8 Key things employees do for successful employment

Both employees and employers identified how employees made their employment positive and successful. This included:

good work ethic

good ‘employee attributes’ (listening skills, honesty, organised, happy, optimistic, intelligent)

knowing themselves, their warning signs, and what they need to do to stay well

good relationships

good communication, open and upfront

keeping the job in perspective

3.9 Advice to other employers

Employers were asked what advice they would give to other employers about hiring people with experience of mental illness. Being open and honest in their relationship with their employee was the most frequently mentioned, alongside not being afraid of being an employer and raising employment issues when necessary. The employers noted that all employees will have issues at times, not just people with experience of mental illness. It was suggested that there may be a need to be slightly more aware of people’s requirements and to respond to those in a meaningful way, to provide support, and have the right skills to do so.

4 Discussion

The aim of this study was to identify critical success factors that enable or sustain open employment of people with experience of mental illness. Amongst the nine themes in the findings, we identified four factors that were key to the successful employment of the participants in this study, and which, given the study limitations discussed later, may apply to others with experience of mental illness. These were: disclosure of mental illness; the relationship between employer and employee; rights and obligations, including the freedom from discrimination; and the work environment.

4.1 Disclosure

Disclosure may be voluntary or obligatory, and there is little discussion in the literature as to the effect of disclosure on the ongoing careers of people with experience of mental illness.

Where disclosure is voluntary, previous research merely advises that disclosure is a difficult decision and there is a need for an employee to plan their disclosure about their mental illness to an employer. The experience of our research participants demonstrated a clear divide between those who disclosed at the beginning of the employment process, usually at the interview stage, and those who disclosed during their employment, usually after becoming unwell. While the timing of disclosure was different, the outcome was similar, and the employees did not seem to experience any regrets about their choice of timing.

There are arguments both for disclosing at the beginning of employment or later during employment. Being upfront at the beginning feels more ‘honest’ to some, and may make the employment process easier to navigate if all the parties are aware of any potential difficulties that may arise and arrangements that may be put in place to counter these. A reason in favour of disclosing at the beginning of the employment relationship, is that if discrimination then occurs, it happens before the employee has invested too much into the relationship.

The participants in this study who disclosed later in their employment delayed because they did not initially realise their mental illness would significantly affect their employment. Delaying disclosure to when they become unwell can, and did for some, however, lead to worry and significant stress due to the employee’s investment in the employment relationship, as well as financial concerns about losing a job. However, employers are also heavily invested in the relationship. Once their employee disclosed their mental illness, the employers in this study went out of their way to retain them. By not disclosing at the beginning, one could argue, that employees benefit from the employer being more receptive and committed to supporting the employee as a result of having already made a substantial investment in theperson.

The participants indicated that the decision about disclosure involved weighing up the risk of an adverse versus a positive reaction from an employer to a person’s experience of mental illness. While people with experience of mental illness may be protected to a greater or lesser extent by anti-discrimination legislation, the literature is full of examples of discrimination. This research, however, illustrates some of the positive stories. In our view, it must always be a decision that is left up to an individual, but we now argue that early, full disclosure may offer greater potential benefit. Disclosing at the beginning of the employment relationship did not disadvantage those who did disclose and by disclosing right away an employee has control over their disclosure; they do not have to worry about who knows and who does not. They are not too invested in the process if their potential employer discriminates and refuses to hire them. Legally they are in a stronger position, and in political terms, the more people who disclose and who are ‘out and proud’ [69] the stronger the mental illness anti-discrimination movement becomes, and the easier it becomes for the next person in thatposition.

From the experiences of the participants in our study, therefore, we are inclined to believe one success factor that enables open employment of people with experience of mental illness is early and frank disclosure of experience of mental illness. However, we acknowledge that this finding may be limited due to only positive employer-employee relationships being included in the study design.

4.2 The employment relationship

An open door policy was cited by both employees and employers as important in maintaining a good employment relationship. It meant that the employee could raise issues as they occurred, and the employer could deal with these issues in a timely manner. This was especially important when it came to employees managing their early warning signs of worsening mental illness.

As a result of the support they had received from their employers, and the positive working environments, employees often expressed a keen sense of reciprocity, commitment and loyalty to the employer and organisation. This was frequently reflected in people making an extra effort to be present, focused and productive.

A potentially adverse implication of this is that employees may be reluctant to leave an employer who has treated them well, thus limiting their career opportunities.

Many of the employees described their employers in glowing terms, almost as friends rather than employers. However, the employers were always clear that they were employers first, and that they had obligations as an employer. Advice from one employer was that employers should not be afraid of being employers – they had an obligation to raise employment issues should they occur.

Another critical success factor identified is the need for an open, honest and reciprocal relationship between employee and employer.

4.3 Employment rights and obligations/freedom from discrimination

Contact between people with experience of mental illness and others is known to be most effective in countering stigma and discrimination towards people with experience of mental illness [70]. We found that employers who had more extensive contact with people with experience of mental illness (rather than just the one employee) were more likely to see their experience as generalizable.

There were several examples in this research where people were not only seen as valued colleagues, but also as valued resources when it came to mental illness in the workplace. The effect of having someone with experience of mental illness in the workplace who is ‘out’ about their experiences has the potential to change a workplace. If the person maintains control over their disclosure and their work presence, they are maintaining equal status with colleagues, a prerequisite for the type of contact required to counter stigma and discrimination.

When it comes to mental illness, it can be argued that currently New Zealand is a much more accepting place than it was even ten years ago. The Like Minds anti-discrimination campaign and the National Depression Initiative have contributed to a more open climate. We suspect that this is why we were successful in gaining participants for our study which required us to find employee and employer pairs who both were willing to be interviewed. Not only did we find them, but several chose to participate in such a way that they could be identified. The voluntary nature of participation in the study meant it would have been surprising for us to have found examples of discrimination in the employment relationships we were investigating. However, it needs a positive legal, cultural and safe employment environment to create the climate where such positive stories are possible.

A climate that is free from stigma and discrimination backed up by a legal system outlining employee and employer rights and obligations is, we believe, a further critical success factor in the employment of people with experience of mental illness.

4.4 The workplace environment

Employees perceived their need for accommodations to be more extensive than employers did. The employers said that where special arrangements were in place they were generally no greater than those provided for other employees, and were mainly reflective of good employment practice, such as flexible working hours or sick leave entitlements. The findings of this research challenge the perception that people with experience of mental illness are difficult to manage and take a lot of time off work. It seems that once mental illness is out in the open and special arrangements are discussed and agreed upon, employees are able to use these special arrangements to help combat their warning signs, reducing the effects mental illness has on their employment.

Employers in this research tended to see their employees as individuals first and people with experience of mental illness second.

Most of the employees had had ‘bad’ employment experiences at some stage in their past. This had had a significant impact on their wellness at the time and had left them wary about approaching new employment experiences. However, in their current roles they have found a job which was the ‘right fit’ for them. This meant they were in the ideal position of being able to compare and contrast their ‘bad’ and ‘good’ experiences.

The difference between ‘good’ employment and ‘bad’ employment was dependent on how well an employer provided a ‘mentally healthy’ environment, and if the employee became unwell, how supportive the employer was in helping their employee get well again.

Our final critical success factor is a workplace that is flexible enough to meet the needs of both employees and employers.

4.5 Limitations

The main limitation of this study could be attributed to the nature of the sample. We aimed to identify positive experiences in open employment of mental health service users. This meant that those who participated in the study had disclosed their experience of mental illness to their employer, and were therefore more likely to have had positive experiences, and less likely to have experienced discrimination from that employer. Therefore, the employer, sourced through the employee, was less likely to be critical of the employee. The learnings from these positive stories however, are valuable in that they provide a perspective often missing from the mental health and employment literature which is often approached through a deficit model.

Because people who were known to the investigators, the advisory group and their networks were one potential source of research participants, this could also have introduced bias. However, only one of the interviewees was personally known to the research team. The lack of younger (under 23) and older (over 65) participants is also a limitation of the study, particularly given that these people possibly face multi-faceted barriers in their pursuit of employment. A number of employees who were keen to participate were precluded from doing so because their employers were either unable or unwilling to participate. Many of the employees whose employers did not take part expressed a real sense of disappointment at not being able to participate themselves. There were also some individuals who wished to participate but were precluded because they did not want to involve their employer either because they had not disclosed their experience of mental illness or because of the added work it would require on their employer’s behalf. The tight timeframe associated with the research (e.g. needing to conduct all the interviews within a seven week period) was also a possible barrier for some employers. By restricting our study to open employment, the valuable role that supported employment services can play in enabling and/or sustaining the employment of people with experience of mental illness was not addressed in this study, as others have dealt with this aspect [20, 71].

5 Conclusion

We interviewed the employees taking one ‘snapshot’ during their career. We have shed light on the employment situations of a group of people not often researched – people with experience of mental illness in open, rather than supported employment. Four critical success factors in their employment were identified relating to disclosure, the employment relationship, freedom from discrimination and workplace flexibility. These success factors may not be able to be generalised to the employment situations of all people with experience of mental illness, however more research into the role the identified success factors play in the employment of this group would be useful.

Future research could also focus on factors that influence successful long term career progression for people with experience of mental illness.

If we are to encourage people with experience of mental illness to enter or maintain employment, then their experiences need to be as positive as possible. The critical success factors that we have identified here go some way to achieving this outcome.

Conflict of interest

The authors have no conflict of interest to report.

References

Arbesman

, Logsdon

. Occupational therapy interventions for employment and education for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy 2011;65:238–46.

Gruhl

, Kauppi

, Montgomery

, James

. Consideration of the influence of place on access to employment for persons with serious mental illness in northeastern Ontario. Rural and Remote Health 2012;12(2034):1–13.

Harris

, Matthews

, Penrose-Wall

, Alam

, Jaworski

. Perspectives on barriers to employment for job seekers with mental illness and additional substance-use problems. Health & Social Care in the Community 2014;22(1):67–77.

Harvey

, Modini

, Christensen

, Glozier

. Severe mental illness and work: What can we do to maximise the employment opportunities for individuals with psychosis? Australian & New Zealand Journal of Psychiatry 2013;47(5):421–4.

Jackson

, Kelland

, Cosco

, McNeil

, Reddon

. Nonvocational outcomes of vocational rehabailitation: Reducation in health services utilization. Work 2009;33:381–7.

Krupa

, Kirsh

, Cockburn

, Gewurtz

. Understanding the stigma of mental illness in employment. Work 2009;33:413–25.

Leufstadius

, Eklund

, Erlandsson

. Meaningfulness in work - Experiences among employed individuals with persistent mental illness. Work 2009;34:21–32.

Levinson

, Lakoma

, Petukhova

, Schoenbaum

, Zaslavsky

, Angermeyer

, et al. Associations of serious mental illness with earnings: Results from the WHO World Mental Health surveys. The British Journal of Psychiatry 2010;197(2):114–21.

Lockett

, Bensemann

. Employment as a health intervention - the role of psychiatry in bridging the evidence to practice gap. Australian & New Zealand Journal of Psychiatry 2013;47(5):417–20.

10.

Matthews

, Harris

, Jaworski

, Alam

, Bozdag

. Function in job seekers with mental illness and drug and alcohol problems who access community based disability employment services. Disability and Rehabilitation (2013);35(6):460–7.

11.

Morgan

. Strategies for improving employment outcomes for people with psychosis. Commentary on: Severe mental illness and work - What can we do to maximise employment opportunities for individuals with psychosis? Australian & New Zealand Journal of Psychiatry 2013;47(5):486–7.

12.

Schofield

, Shrestha

, Percival

, Kelly

, Passey

, Callander

. Quantifying the effect of early retirement on the wealth of individuals with depression or other mental illness. The British Journal of Psychiatry 2011;198(2):123–8.

13.

Viering

, Bartsch

, Obermann

, Rusch

, Rossler

, Kawohl

. The effectiveness of individual placement and support for people with mental illness new on social benefits: A study protocol BMC Psychiatry 2013;13(195):1–6.

14.

Villotti

, Corbiere

, Zaniboni

, Fraccaroli

. Individual and environmental factors related to job satisfaction in people with severe mental illness employed in social enterprises. Work 2012;43:33–41.

15.

Abraham

, Stein

. Case managers’ expectations about employment for people with psychiatric disabilities. Psychiatric Rehabilitation Journal 2009;33(1):9–17.

16.

Dunn

, Wewiorski

, Rogers

. A qualitative investigation of individual and contextual factors associated with vocational recovery among people with serious mental illness. American Journal of Orthopsychiatry 2010;80(2):185–94.

17.

Giugiario

, Crivelli

, Mingrone

, Montemagni

, Scalese

, Sigaudo

, et al. Cognitive function and competitive employment in schizophrenia: Relative contribution of insight and psychopathology. Social Psychiatry and Psychiatric Epidemiology 2011;47(4):553–61.

18.

Heffernan

, Pilkington

. Supported employment for persons with mental illness: Systematic review of the effectiveness of individual placement and support in the UK. Journal of Mental Health (2011);20(4):368–80.

19.

Nordt

, Brantschen

, Kawohl

, Beartsch

, Haker

, Rusch

, et al. ‘Placement budgets’ for supported employment - improving competitive employment for people with mental illness: Study protocol of a multicentre randomized controlled trial. BMC Psychiatry 2012;12(165).

20.

Catty

, Lissouba

, White

, Becker

, Drake

, Fioritti

, et al. Predictors of employment for people with severe mental illness: Results of an international six-centre randomised controlled trial. The British Journal of Psychiatry 2008;192(3):224–31.

21.

Erickson

, Jaafari

, Lysaker

. Insight and negative symptoms as predictors of functioning in a work setting in patients with schizophrenia. Psychiatry Research 2011;189(2):161–5.

22.

Dunn

, Wewiorski

, Rogers

. The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study. Psychiatric Rehabilitation Journal 2008;32(1):59–62.

23.

Henderson

, Williams

, Little

, Thornicroft

. Mental health problems in the workplace: Changes in employers’ knowledge, attitudes and practices in England 2006-2010. The British Journal of Psychiatrys 2013;202(s55):s70–s6.

24.

Lauber

, Bowen

. Low mood and employment: When affective disorders are intertwined with the workplace–A UK perspective. International Review of Psychiatry 2010;22(2):173–82.

25.

Swales

. Mental health in the workplace. Training Journal 2012:50–4.

26.

Harvey

, Henderson

, Lelliott

, Hotopf

. Mental health and employment: Much work still to be done. The British Journal of Psychiatry 2009;194(3):201–3.

27.

Statistics New Zealand. Disability Survey: 2013. Wellington: Statistics New Zealand, 2014.

28.

Statistics New Zealand. Disability and the labour market in New Zealand in 2006. Wellington: Statistics New Zealand, 2008.

29.

Sutton

, Hocking

, Smythe

. A phenomenological study of occupational engagement in recovery from mental illness. Canadian Journal of Occupational Therapy 2012;79(3):142–50.

30.

McHugo

, Drake

, Xie

, Bond

. A 10-year study of steady employment and non-vocational outcomes among people with serious mental illness and co-occurring substance use disorders. Schizophrenia Research 2012;138(2-3):233–9.

31.

Rinaldi

, Killackey

, Smith

, Shepherd

, Singh

, Craig

. First episode psychosis and employment: A review. International Review of Psychiatry 2010;22(2):148–62.

32.

Shankar

, Barlow

, Khalema

. Work, Employment, and mental illness: Expanding the domain of Canadian social work. Journal of Social Work in Disability & Rehabilitation 2011;10(4):268–83.

33.

McGurk

, Mueser

, DeRosa

, Wolfe

. Work, recovery, and comorbidity in schizophrenia: A randomized controlled trial of cognitive remediation. Schizophrenia Bulletin 2009;35(2):319–35.

34.

Niekerk

. Participation in work: A source of wellness for people with psychiatric disability. Work 2009;32:455–65.

35.

Douglas

. Employers face obstacles in dealing with employee mental health. HR Focus 2013;90(11):3–5.

36.

Panel on Labour Market Opportunities for Persons with Disabilities. Rethinking disability in the private sector: We all have abilities. Some are just more apparent than others. Canada: Public Works and Government Services, 2013.

37.

Graffam

, Smith

, Shinkfield

, Polzin

. Employer benefits and costs of employing a person with a disability. Journal of Vocational Rehabilitation 2002;17:251–63.

38.

Chatterji

, Alegria

, Takeuchi

. Psychiatric disorders and labor market outcomes: Evidence from the National Comorbidity Survey-Replication. Journal of Health Economics 2011;30(5):858–68.

39.

Swanson

, Langfitt-Reese

, Bond

. Employer attitudes about criminal histories. Psychiatric Rehabilitation Journal 2012;35(5):385–90.

40.

Kirsh

, Stergiou-Kita

, Gewurtz

, Dawson

, Krupa

, Lysaght

, et al. From margins to mainstream: What do we know about work integration for persons with brain injury, mental illness and intellectual disability? Work 2009;32:391–405.

41.

Tsang

HWH

, Angell

, Corrigan

, Lee

Y-T

, Shi

, Lam

, et al. A cross-cultural study of employers’ concerns about hiring people with psychotic disorder: Implications for recovery. Social Psychiatry and Psychiatric Epidemiology 2007);42(9):723–33.

42.

Steemson

. Out of the depths. The RoSPA Occupational Safety and Health Journal 2009;October:23–7.

43.

Cummings

, Lucas

, Druss

. Addressing public stigma and disparities among persons with mental illness: The role of federal policy. American Journal of Public Health 2013;103(5):781–5.

44.

Corrigan

, Powell

, Rüsch

. How does stigma affect work in people with serious mental illnesses? Psychiatric Rehabilitation Journal 2012;35(5):381–4.

45.

Henderson

, Brohan

, Clement

, Williams

, Lassman

, Schauman

, et al. A decision aid to assist decisions on disclosure of mental health status to an employer: Protocol for the CORAL exploratory randomised controlled trial. BMC Psychiatry 2012;12(133).

46.

Bergmans

, Carruthers

, Ewanchuk

, James

, Wren

, Yager

. Moving from full-time healing work to paid employment: Challenges and celebrations. Work 2009;33:389–94.

47.

Peterson

, Currey

, Collings

. “You Don’t Look Like One of Them”: Disclosure of mental illness in the workplace as an ongoing dilemma. Psychiatric Rehabilitation Journal 2011;35(2):145–7.

48.

Corbiere

, Lanctot

. Salient components in supported employment programs: Perspectives from employment specialists and clients. Work 2011;39:427–39.

49.

King

, Cleary

, Harris

, Lloyd

, Waghorn

. Employment-related information for clients receiving mental health services and clinicians. Work 2011;39:291–303.

50.

National Institute for Health and Clinical Excellence. Promoting mental wellbeing at work, NICE, 2009.

51.

Mental Health First Aid England. Line managers’ resource: A practical guide to managing and supporting people with mental health problems in the workplace. MHFA England; 2013.

52.

Norriss

. Mentally health workplaces, Lawtalk 2013.

53.

Burns

, Catty

, White

, Becker

, Koletsi

, Fioritti

, et al. The impact of supported employment and working on clinical and social functioning: Results of an international study of individual placement and support. Schizophrenia Bulletin 2008;35(5):949–58.

54.

Bush

, Drake

, Xie

, McHugo

, Haslett

. The long-term impact of employment on mental health service use and costs for persons with severe mental illness. Psychiatric Services 2009;60(8):1024–31.

55.

Campbell

, Bond

, Drake

. Who benefits from supported employment: A meta-analytic study. Schizophrenia Bulletin 2009;37(2):370–80.

56.

Michon

, Weeghel

, Kroon

, Schene

. Illness self-management assessment in psychiatric vocational rehabilitation. Psychiatric Rehabiliation Journal 2011;35(1):21–7.

57.

Russinova

, Bloch

, Lyass

. Patterns of employment among individuals with mental illness in vocational recovery. Journal of Psychosocial Nursing 2007;45(12):48–54.

58.

Campbell

, Bond

, Drake

, McHugo

, Xie

. Client Predictors of Employment Outcomes in High-Fidelity Supported Employment. The Journal of Nervous and Mental Disease 2010;198(8):556–63.

59.

Twamley

, Vella

, Burton

, Becker

, Bell

, Jeste

. The efficacy of supported employment for middle-aged and older people with schizophrenia. Schizophrenia Research 2012;135(1-3):100–4.

60.

Waynor

, Pratt

. Barriers to vocational effectiveness in ACT: Staff perspectives. Journal of the American Psychiatric Nurses Association 2011;17(1):72–9.

61.

Blank

, Peters

, Pickvance

, Wilford

, MacDonald

. A systematic review of the factors which predict return to work for people suffering episodes of poor mental health. Journal of Occupational Rehabilitation 2008;18(1):27–34.

62.

Ellison

, Russinova

, MacDonald-Wilson

, Lyass

. Patterns and correlates of workplace disclosure among professionals and managers with psychiatric conditions. Journal of Vocational Rehabilitation 2003;18:3–13.

63.

Cresswell

. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, California: Sage Publications; 1998.

64.

Palinkas

, Horwitz

, Green

, Wisdom

, Duan

, Hoagwood

. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health 2013.

65.

Patton

. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, California: Sage Publications; 2002.

66.

Bowling

. Research methods in health: Investigating health and health services. 3rd ed. Maidenhead, Berkshire: Open University Press; 2009.

67.

Green

, Thorogood

. Qualitative methods for health research. 2nd ed. London: Sage Publications Ltd; 2009.

68.

Gibbs

. Analyzing Qualitative Data. Los Angeles: Sage Publications; 2007.

69.

Corrigan

, Kosyluk

, Rusch

. Reducing self-stigma by coming out proud. American Journal of Public Health 2013;103(5):794–800.

70.

Gordon

. The Power of Contact. Wellington: Case Consulting, 2005.

71.

Bond

, Drake

, Becker

. Generalizability of the individual placement and support (IPS) model of supported employment outside the US. World Psychiatry 2012;11:32–9.